Diabetic Leg Pain and Peripheral Arterial Disease

Cramping, pain, or tiredness in the legs when walking or climbing stairs – these may not sound like symptoms of a serious condition. In fact, many people believe that they are normal signs of aging. But they can be signs of peripheral arterial disease, a severe condition that can lead to gangrene and amputation if left untreated. So if you have these symptoms, be sure to tell your doctor.

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Peripheral arterial disease (PAD) is a condition in which arteries leading to the legs and feet (or in some cases the arms) become clogged with fatty deposits called plaque, resulting in reduced or blocked blood flow to these areas. It affects between 8 million and 12 million Americans, and people with diabetes are more likely to develop PAD than the general population. PAD is also known as peripheral vascular disease (PVD), leg atherosclerosis, or simply poor circulation.

PAD and diabetes

Anyone can develop PAD, but people with diabetes, especially those with Type 2 diabetes, have a higher risk of developing it because of a series of bodily changes associated with diabetes, including insulin resistance, a higher level of blood fats, and an increase in blood pressure. All of these contribute to arteries becoming clogged with fatty deposits, leading to the hardening and narrowing of these blood vessels.

Having diabetes also increases the risk of developing neuropathy, or nerve damage, as a result of high blood glucose. Neuropathy can cause decreased sensation in the feet and legs, which can cause a person not to notice small injuries to the foot, such as blisters or cuts. If a person continues to walk on an injury, it is likely to enlarge and get infected.

The combination of PAD and neuropathy is particularly dangerous because when blood flow to the feet is reduced, the body has a harder time healing injuries to the feet and fighting infection. A wound that goes unnoticed and that the body cannot heal on its own may become severely infected and develop into an ulcer.

And that’s not all that can go wrong. If you have PAD, you may also have clogged blood vessels in your heart or brain, putting you at higher risk for heart attack and stroke. In fact, having PAD means there is a one-in-four chance that you will experience a heart attack, stroke, amputation, or even death in the next five years.

Warning signs and symptoms

One symptom of PAD that is hard to ignore is pain, which can occur in the legs, feet, or toes, and often interrupts sleep. Pain may also increase with walking and let up with sitting; this type of pain is called claudication. Sometimes it may not be actual pain, but rather a feeling of heaviness, tiredness, or cramping that occurs in the buttocks, thighs, or calves. The pain or discomfort can limit your ability to do everyday activities like shopping or going out with friends. Since PAD often interferes with activities that bring enjoyment, it can also take a mental toll by leading to feelings of isolation and confinement.

Another sign of PAD is that sores on the legs or feet heal slowly (longer than 8 to 12 weeks) or don’t heal at all. Feet may feel cold because of decreased blood flow. When this happens, you may notice that one foot or leg seems colder than the other, although sometimes both are cold. Cold feet can be a subtle sign; if you have a spouse, he or she may notice them more than you do, particularly when you sleep at night.

Other things you may notice if you have PAD include color changes in your feet (paleness or blueness), poor nail growth, and decreased hair growth on your toes or legs.

It is also possible to have PAD with no symptoms. In people with diabetes, PAD often affects smaller blood vessels below the knee, which makes it less likely to cause pain and other symptoms. In fact, almost 50% of people with diabetes who have PAD experience no symptoms at all. This is in part because many people with diabetes have neuropathy and decreased sensation in their legs. For other people, symptoms may be so subtle or develop so gradually that they do not seem worth reporting to a health-care provider. Symptoms that are commonly ignored include walking more slowly, an inability to walk long distances due to pain, and a feeling of heaviness or fatigue in the legs.

Even if you do not have symptoms, or if the symptoms you have do not interfere with your daily activities, having diabetes alone is reason enough to be concerned about PAD. Like other vascular diseases (diseases of the heart and blood vessels), it can be “silent” until it causes a severe problem such as a blood clot that results in lasting damage.

Screening

The American Diabetes Association recommends that if you are over 50 and have diabetes, you should be screened for PAD even if you have no symptoms. If you are under the age of 50 and have risk factors such as smoking, high blood pressure, high cholesterol, or having had diabetes for more than 10 years, you should be screened, as well.

How does one go about getting screened? First, see your health-care provider. A doctor will most likely ask you a series of questions to evaluate your risk and also look at your feet to see if you have physical signs of PAD (cold feet, decreased hair growth on the toes, ulcers that are slow to heal, or a weak pulse in the feet). Once your doctor determines that you are at risk for PAD, he may perform a test (or refer you to someone else to do the test) called an ankle—brachial index (ABI). The ABI test is painless and noninvasive, and it takes about 20—30 minutes to perform. You will be asked to lie down for about 10 minutes so that the effect of gravity is the same on your arms and legs; this is necessary to get accurate results. Then the doctor or nurse will measure the blood pressure in your arms and in two places on each foot with a handheld device called a Doppler probe. The Doppler probe uses sound waves to detect blood flow. Only the systolic blood pressure (the “top number”) will be recorded for each site. The blood pressure in your ankles will be compared to the blood pressure in your arms. If it is lower in the ankles than in the arms, you may have PAD.

The ABI is a screening test, so it cannot tell you where a blockage or narrowing of the arteries is located. To determine the location and extent of a blockage, you will most likely be referred to a peripheral vascular specialist for further testing. These tests can include an ultrasound, magnetic resonance imaging (MRI), or an angiogram (an x-ray test to look at blood flow).

Once you know whether you have PAD, treatment will depend on the location and extent of the blockage. The goal of the treatment will be to improve your quality of life and to prevent a heart attack, stroke, or amputation.

Treatment options

There are generally three treatment options for PAD. These include lifestyle changes (discussed in the next section on risk factors), drug treatment, and surgery.

You may already take medicines that can help reduce your risk of PAD, such as diabetes drugs, cholesterol-lowering drugs, and blood-pressure-lowering drugs. In addition, your doctor may prescribe an antiplatelet drug to decrease the risk of developing clots in your blood vessels.

There are several surgical options for the treatment of PAD. One, with which many people are familiar, is an angioplasty. This procedure is often used when there is a blockage leading to the heart, but it can also be done for PAD. To perform it, a doctor inserts a small tube with a balloon at its end into the affected artery. The balloon is inflated, opening the narrowed area. Sometimes a stent, a tiny wire mesh tube, is inserted to keep the artery open. Another procedure that can be done is an artery bypass. This surgery, too, is commonly performed in the heart, and is often used when the blockage is more complete and cannot be opened by an angioplasty. In this procedure, a blood vessel is taken from another part of the body and reattached around the blocked section of artery.

A more recently developed treatment is plaque removal. In this procedure, a small tube is inserted into the affected artery, and a tiny rotating blade is used to shave plaque from the artery wall as the doctor advances the tube through the artery. This is generally not a possibility if an artery is nearly or fully blocked.

Risk factors

What can you do to reduce your risk of developing PAD? The first step is to know the risk factors. Some that you cannot change include the following:

Your age. Simply being over the age of 50 increases your risk of PAD.

Having diabetes. One in four people over the age of 50 with diabetes has PAD.

Your ethnicity. African-Americans are twice as likely to have PAD as Caucasians. Hispanics are also at increased risk for PAD.

Your personal history. If you have had vascular disease, a stroke, or a heart attack, you have a one-in-three chance of developing PAD.

You are also at risk if you have a family history of heart disease or diabetes.

There are also some risk factors that you can modify through lifestyle changes, including these:

Diabetes control. Keep your HbA1c level (a measure of diabetes control over the past two to three months) within the target range that you and your doctor have established. The American Diabetes Association recommends an HbA1c level of below 7%, or as close to normal as possible.

Smoking. If you smoke or have a history of smoking, your risk of developing PAD is multiplied by four. Smoking is one of the biggest, and most avoidable, risks for developing PAD. Even if you already have PAD, you can halt or even reverse the progression of the disease by stopping smoking. So if you smoke, find a way to quit!

High blood pressure. The established blood pressure goal for individuals with diabetes is below 140/80 mm Hg. Numerous lifestyle measures can help you lower your blood pressure, including making dietary changes such as reducing your sodium intake; engaging in regular physical activity; losing weight if you’re overweight; learning and practicing relaxation techniques such as meditation or guided imagery; and keeping your alcohol intake moderate. If these steps are not enough, your doctor may prescribe one or more blood-pressure-lowering drugs

High blood cholesterol. If your LDL (low-density lipoprotein, or
“bad”) cholesterol is higher than 100 mg/dl, you have a greater risk of developing PAD. Know your cholesterol numbers, and ask your doctor for a copy of your lab test results so that you can track your progress. Many of the lifestyle changes that help lower blood pressure are also good for cholesterol levels. It may also help to meet with a dietitian for specific advice on food choices. If necessary, your doctor may recommend that you take a medicine to increase your HDL (high-density lipoprotein, or “good”) cholesterol and decrease your LDL cholesterol level.

The good news about PAD is that it can be prevented with the same healthy lifestyle that lowers the risk of most major diabetes complications. In addition, if detected early, PAD can be stopped and reversed, so it’s important to get screened regularly for PAD, be aware of its signs and symptoms, and seek treatment immediately if a problem or symptom arises. By taking steps to prevent or halt vascular disease, you can raise the likelihood of being able to live your life the way you want to.

Dr. Malaskovitz is director of the Diabetes Treatment Center and the Leg Circulation Center at Desert Springs Hospital in Las Vegas, Nevada. Dr. Michael is an associate professor emeritus at the University of Nevada, Las Vegas, and a nurse clinician at the Diabetes Treatment Center at Desert Springs Hospital in Las Vegas, Nevada.

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